Dr. Mage et al have questioned our description of the pathophysiology and genetics of SIDS.1 They state that there are three causal factors for SIDS – gender, age, and birth order – that are all independent of sleep position. We respectfully disagree with their assertion.

The data for sudden and unexpected infant death (SUID), which includes ICD-10 codes for SIDS (R95), accidental suffocation and strangulation in bed (W75), and ill-defined deaths (R99), for 2013-2015 show that 6175 males and 4433 females died.2 This calculates to a 28% excess rate in males. This excess has decreased since 1994 (when the Back to Sleep campaign began). While we cannot say that this change in the male:female ratio is a result of changes in sleep position, this change does indicate that there are factors that have affected this ratio in recent decades.

Similarly, the age distribution for SUID has shifted to younger ages in recent years. Whereas the peak age distribution was 2-4 months of age in the 1990s-2000s3,4, a greater proportion of deaths are now being seen before 1 month. From 1995-1998, 6.5% of SIDS and 9.8% of SUID occurred before 28 days of age. In 2007-2013, 8.9% of SIDS and 11.7% of SUID occurred before 28 days of age.2
With regards to birth order, in 1995-1998, the rate of both SIDS and SUID increased with birth order. However, in 2007-2013, the rate of SIDS was 0.013/1000 live births (LB) for the first child, 0.012/1000 LB for the second child, and 0.019/100...

Dr. Mage et al have questioned our description of the pathophysiology and genetics of SIDS.1 They state that there are three causal factors for SIDS – gender, age, and birth order – that are all independent of sleep position. We respectfully disagree with their assertion.

The data for sudden and unexpected infant death (SUID), which includes ICD-10 codes for SIDS (R95), accidental suffocation and strangulation in bed (W75), and ill-defined deaths (R99), for 2013-2015 show that 6175 males and 4433 females died.2 This calculates to a 28% excess rate in males. This excess has decreased since 1994 (when the Back to Sleep campaign began). While we cannot say that this change in the male:female ratio is a result of changes in sleep position, this change does indicate that there are factors that have affected this ratio in recent decades.

Similarly, the age distribution for SUID has shifted to younger ages in recent years. Whereas the peak age distribution was 2-4 months of age in the 1990s-2000s3,4, a greater proportion of deaths are now being seen before 1 month. From 1995-1998, 6.5% of SIDS and 9.8% of SUID occurred before 28 days of age. In 2007-2013, 8.9% of SIDS and 11.7% of SUID occurred before 28 days of age.2
With regards to birth order, in 1995-1998, the rate of both SIDS and SUID increased with birth order. However, in 2007-2013, the rate of SIDS was 0.013/1000 live births (LB) for the first child, 0.012/1000 LB for the second child, and 0.019/1000 LB for subsequent children. Rates for SUID in 2007-2013 show a similar pattern.2

The current evidence does not implicate these three factors as causal and does not offer any causal mechanisms. We disagree that these three characteristics are “better than the triple risk model;” rather, we consider all of these factors to be part of the Triple Risk Model. The male predominance may be one explanation for the vulnerability of the infant, infant age is consistent with the proposed “critical developmental period,” and birth order and possible spread of respiratory infections may contribute to the “exogenous stressors.”

We are concerned by the authors’ conclusion that “the prone sleeping position, overbundling, and co-sleeping are neither necessary nor sufficient causal factors because infants die of SIDS in the supine position, unbundled while sleeping alone.” While it is true that infants can die in the supine position, unbundled while sleeping alone, this is a small minority of cases. Ostfeld’s review of SIDS cases in New Jersey found that only 2 (0.8%) of all 244 cases were risk-free. When nonmodifiable risks were excluded, 5.3% of the cases met this definition.5 Data from the CDC SUID case registry showed that, among SUID cases with complete information, only 3% were found in environments without unsafe sleep factors.6 Further, thus far the only declines in SUID rates have been associated with changes in practice, particularly with regards to sleep position.

The SIDS Task Force have done an excellent review of exogenous triggers or “stressors” (e.g., prone sleep position, over bundling, co-sleeping with airway obstruction, etc.) for SIDS. However, it has been shown that there is no difference between pathological findings of prone and supine SIDS [1]. The report seems to overlook the properties of SIDS indicative of causal factors that have not changed while the preferred infant sleeping position changed from prone to supine:
1. SIDS have a 50% male excess independent of sleep position;
2. SIDS have a 4-parameter lognormal age distribution with parameters independent of sleep position;
3. SIDS have an increasing rate with increasing live birth order, independent of sleep position.

1. The 50% male excess in SUID (SIDS+UNK+ASSB) is reported by the CDC Wonder database (1968-2015) as 119,201 male and 79,629 female post-neonatal cases (28-364 days) for a male fraction of 0.600. Naeye et al. [2] claimed that this 50% male excess in infant mortality must be X-linked. We agreed, and have proposed that an X-linked recessive allele with frequency q = 2/3 that is not protective against acute anoxic encephalopathy would place XY males at risk of SUID with frequency q = 2/3 and XX females at risk with frequency q*q = 4/9, providing the 50% excess male risk for equal numbers of males and females at risk. [3] The male 50% excess is independent of sleep position.
2. The 4-parameter lognormal age distribution of...

The SIDS Task Force have done an excellent review of exogenous triggers or “stressors” (e.g., prone sleep position, over bundling, co-sleeping with airway obstruction, etc.) for SIDS. However, it has been shown that there is no difference between pathological findings of prone and supine SIDS [1]. The report seems to overlook the properties of SIDS indicative of causal factors that have not changed while the preferred infant sleeping position changed from prone to supine:
1. SIDS have a 50% male excess independent of sleep position;
2. SIDS have a 4-parameter lognormal age distribution with parameters independent of sleep position;
3. SIDS have an increasing rate with increasing live birth order, independent of sleep position.

1. The 50% male excess in SUID (SIDS+UNK+ASSB) is reported by the CDC Wonder database (1968-2015) as 119,201 male and 79,629 female post-neonatal cases (28-364 days) for a male fraction of 0.600. Naeye et al. [2] claimed that this 50% male excess in infant mortality must be X-linked. We agreed, and have proposed that an X-linked recessive allele with frequency q = 2/3 that is not protective against acute anoxic encephalopathy would place XY males at risk of SUID with frequency q = 2/3 and XX females at risk with frequency q*q = 4/9, providing the 50% excess male risk for equal numbers of males and females at risk. [3] The male 50% excess is independent of sleep position.
2. The 4-parameter lognormal age distribution of SIDS with a peak rate at or about 2 months after birth is independent of sleeping position. It has not changed with changing preferred sleep position from prone to supine [4];
3. SIDS have a constant increasing rate with increasing live birth order, independent of sleeping position, that is like that for infant mortality from respiratory infection [5]. We have shown that a fulminating prodromal respiratory infection in a genetically X-linked susceptible infant can explain these three characteristics of SIDS better than the triple risk model cited by the authors.

For SIDS, the causal factors create the fatal encephalopathy with the fixed age and gender distributions. The prone sleeping position, over-bundling and co-sleeping are neither necessary nor sufficient causal factors because infants die of SIDS in the supine sleep position, unbundled while sleeping alone. In conclusion, we hold the prone sleep position is an important risk factor for SIDS that must be strongly discouraged to the public, but that researchers should keep in mind that it is strictly neither necessary nor sufficient to cause SIDS.

Dr. Frankel and Mr. Cooper have questioned the recommendation that infants sleep in the parental bedroom, on a separate sleep surface close to the parents’ bed, ideally for a year, but at least for 6 months.(1)

First, we would like to note that the 2016 policy statement is not significantly different from the 2011 policy statement with regards to roomsharing. For some inexplicable reason, the media chose to highlight the "roomsharing ideally for a year, but at least for 6 months" as an important and more stringent change. In fact, in 2011, our recommendation was that all of the recommendations should be followed until the baby is 1 year of age. So, this was a loosening of the recommendations. We believe that the most important changes in the recommendations about sleep location are: 1) babies should never fall asleep on couches, sofas, or cushioned chairs, and 2) parents who may fall asleep while feeding their baby in their adult bed should rid the bed of any extraneous bedding.

Case-control studies in England, New Zealand, and Scotland have demonstrated that roomsharing decreases the risk of SIDS, when compared to sleeping in a separate room. Our statement that the decline in risk was approximately 50% is very conservative. Blair’s study found that the adjusted odds ratio of death for infants who slept in a separate room, compared with those who slept in the parents’ room, was 10.49 (95% CI 4.26-25.81).(2) The New Zealand Cot Death study found...

Dr. Frankel and Mr. Cooper have questioned the recommendation that infants sleep in the parental bedroom, on a separate sleep surface close to the parents’ bed, ideally for a year, but at least for 6 months.(1)

First, we would like to note that the 2016 policy statement is not significantly different from the 2011 policy statement with regards to roomsharing. For some inexplicable reason, the media chose to highlight the "roomsharing ideally for a year, but at least for 6 months" as an important and more stringent change. In fact, in 2011, our recommendation was that all of the recommendations should be followed until the baby is 1 year of age. So, this was a loosening of the recommendations. We believe that the most important changes in the recommendations about sleep location are: 1) babies should never fall asleep on couches, sofas, or cushioned chairs, and 2) parents who may fall asleep while feeding their baby in their adult bed should rid the bed of any extraneous bedding.

Case-control studies in England, New Zealand, and Scotland have demonstrated that roomsharing decreases the risk of SIDS, when compared to sleeping in a separate room. Our statement that the decline in risk was approximately 50% is very conservative. Blair’s study found that the adjusted odds ratio of death for infants who slept in a separate room, compared with those who slept in the parents’ room, was 10.49 (95% CI 4.26-25.81).(2) The New Zealand Cot Death study found that infants who roomshared for the last sleep had a 65% lower risk of death, compared with sleeping in a separate room (aOR 0.35 [95% CI 0.26-0.49]), and usual roomsharing had a similar protective effect.(3) Tappin et al found that the adjusted odds ratio of death when sleeping in a separate room, compared with roomsharing, was 3.26 (95% CI 1.03-10.35).(4) While Tappin’s study only found this reduction in risk to be present if the parent was a smoker, Blair found this reduction to be present for both smoker and nonsmoker parents (Peter Blair, personal communication, 2016). Further, the most recent data from the New Zealand Sudden and Unexplained Death in Infancy (SUDI) study demonstrates a 64% protection with roomsharing, compared with solitary sleeping (aOR 0.36 [95% CI, 0.19-0.71]) (Edwin Mitchell, personal communication, 2016). Unfortunately, these studies did not stratify the risk by infant age in months, which is why we recommended in 2011 that the guidelines be followed for the first year. However, more recent analyses of case-control studies(5,6) and registry databases(7) emphasize the importance in general of sleep location in the first few months of the infant's life, which seems to be a very vulnerable time. 90% of sleep-related deaths occur in the first 6 months, and the peak occurs between 1 and 4 months of age.

An infant’s ability to arouse is critical physiologically - and a leading hypothesis is that failure to arouse makes infants vulnerable to SIDS.(8) The failure to arouse may explain why prone sleeping is so dangerous; infants who sleep prone have higher arousal thresholds. Roomsharing infants have more small awakenings (which may manifest as stirring or moving around and not full awakening) during the night.(9,10) It has been postulated that roomsharing without bedsharing may offer a protective effect from the small awakenings. Further, roomsharing facilitates continued breastfeeding,(11) another measure that reduces the risk.

One study that has looked at the impact of roomsharing on parental sleep quality has shown that roomsharing mothers have more sleep disturbances than mothers who sleep in a separate room.(12) In this study, roomsharing and solitary sleeping infants have similar sleep quality. Other studies have found roomsharing infants to have more frequent awakenings.(9,10) On the other hand, some papers have found that the sleep quality of breastfeeding mothers (who are more likely to be roomsharing) is similar to or better than for formula feeding mothers, and that sleep quantity in these two groups are similar.(13,14) One study found that mothers who exclusively breastfeed sleep, on average, 30 minutes longer than formula feeding mothers.(14)

Clearly more research is needed to better understand the physiology of infant sleep and arousal when infants roomshare with their parents, and the downstream consequences of roomsharing on parental and child sleep.

It is very difficult to take issue with something as serious and well intentioned as guidelines to prevent Sudden Unexpected Infant Death (SUID). However, there are some major unknowns, which make these recommendations unreasonable and even questionable from a child development and family relationships perspective.

All four of the studies cited to evidence room-sharing have been conducted with samples of European parents and European infants. Yes, from a life-saving perspective, it might make sense that parents in the United States are in the same room as their infants for the first year (this has not been studied yet, as just noted) but is this something that parents in our American culture can do? American families are living under very different contexts than European families, most notably, American mothers are expected to and do return to work when their infants are much younger in age than their European counterparts (Berger, Hill, & Waldfogel, 2005). This warrants further consideration by the Task Force representing the American Academy of Pediatrics because these recommendations are being given to mothers who are living under different cultural expectations than mothers of infants in Europe.

Infants in their second half-year of life are more aware of the world around them and, later in their second half-year of life, are developmentally capable of engaging in acts such as vocalizing to get the attention of their parents. Researchers should investi...

It is very difficult to take issue with something as serious and well intentioned as guidelines to prevent Sudden Unexpected Infant Death (SUID). However, there are some major unknowns, which make these recommendations unreasonable and even questionable from a child development and family relationships perspective.

All four of the studies cited to evidence room-sharing have been conducted with samples of European parents and European infants. Yes, from a life-saving perspective, it might make sense that parents in the United States are in the same room as their infants for the first year (this has not been studied yet, as just noted) but is this something that parents in our American culture can do? American families are living under very different contexts than European families, most notably, American mothers are expected to and do return to work when their infants are much younger in age than their European counterparts (Berger, Hill, & Waldfogel, 2005). This warrants further consideration by the Task Force representing the American Academy of Pediatrics because these recommendations are being given to mothers who are living under different cultural expectations than mothers of infants in Europe.

Infants in their second half-year of life are more aware of the world around them and, later in their second half-year of life, are developmentally capable of engaging in acts such as vocalizing to get the attention of their parents. Researchers should investigate how room-sharing impacts parent sleep deprivation and parents’ stress.

Transitioning an infant under the age of six months from room-sharing to his or her own crib is likely much easier than transitioning a twelve month old. Infants in the later part of their second half-year of life are highly aware of the world around them and are used to routines. It seems highly improbable that the transition from room-sharing to sleeping independently will happen without the infant and, in turn, their parents encountering lots of stress if it is done at a year of age.

The members of the Task Force on Sudden Infant Death Syndrome that wrote the 2016 recommendations are a highly respected group of medical doctors with expertise in pediatrics, family medicine and public health. However, their recommendation that children room-share until twelve months of age might not be realistic or optimal at all from both a child development and family relations perspective. This should be investigated by researchers studying sleep safety in the United States from a public health perspective that is more sensitive to emotional needs of infants and the unique cultural context of families living in the United States.

I am skeptical about the logical and empirical support for recommending room-sharing over having the infant sleep in a separate room for the first year of life, and I am very concerned that this recommendation will result in undue stress and other negative consequences for parents who are reluctant to share their room with their infant.
First, even if there was clear support for sharing a room vs having the infant sleep in a crib in a separate room, there is research finding that parents who share the room with their infants sleep more poorly than parents who have their infant in a crib in a separate room. The parents' mental health and sleep quality needs to be considered as well in making these important decisions. Sleep deprivation, depression, and reduced marital satisfaction can all have a serious negative impact on the baby. The risk of SIDS may be outweighed by these other risks.
The authors state: "There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%," It is not clear whether this statistic refers to room-sharing vs. separate room/crib, but I did not find sound evidence that having infants sleep in the same room with parents on a different surface is less risky than having infants sleep in a separate room in a crib. Here are a few problems I found with the studies cited in support of this statement:
1) Some studies are old and predate the recommendation to have infants sleep...Show More

I am skeptical about the logical and empirical support for recommending room-sharing over having the infant sleep in a separate room for the first year of life, and I am very concerned that this recommendation will result in undue stress and other negative consequences for parents who are reluctant to share their room with their infant.
First, even if there was clear support for sharing a room vs having the infant sleep in a crib in a separate room, there is research finding that parents who share the room with their infants sleep more poorly than parents who have their infant in a crib in a separate room. The parents' mental health and sleep quality needs to be considered as well in making these important decisions. Sleep deprivation, depression, and reduced marital satisfaction can all have a serious negative impact on the baby. The risk of SIDS may be outweighed by these other risks.
The authors state: "There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%," It is not clear whether this statistic refers to room-sharing vs. separate room/crib, but I did not find sound evidence that having infants sleep in the same room with parents on a different surface is less risky than having infants sleep in a separate room in a crib. Here are a few problems I found with the studies cited in support of this statement:
1) Some studies are old and predate the recommendation to have infants sleep supine. In at least one study (Scragg et al., 1996) infants may have been at a greater risk in a separate room because they may have been sleeping prone.
2) 'Separate room' in many of these studies doesn't mean sleeping in a crib alone with no soft bedding/blankets. In Blair et al., 1999, a 'solitary sleeper' is an infant who "usually slept in room separate from parents either alone or with other siblings." In Carpenter et al., 2004, “being last left in another room” was associated with greater risk than sleeping with parent but not in the same bed. ‘Another room’ could mean in their own room in a crib alone, or it could mean something else. Thus we don't know that that the reduced risk is purely do to having parents close by to monitor the infant versus some other uncontrolled factors.
3) In many of the studies, some confounding variables are controlled, but not all the relevant variables (e.g., maternal smoking postpartum, alcohol use, bedding/blanket use). Given the strength of the recommendation I’d want to see that all confounds are simultaneously controlled.
At least one study reported that sleeping in a separate room vs shared room was not associated with a higher risk of SIDS in non-smokers.
Also, what supports the recommendation of room sharing for a year vs. six months? I didn't see any research support for this.Show Less

I am skeptical about the logical and empirical support for recommending room-sharing over having the infant sleep in a separate room for the first year of life, and I am very concerned that this recommendation will result in undue stress and other negative consequences for parents who are reluctant to share their room with their infant.

First, even if there was clear support for sharing a room vs having the infant sleep in a crib in a separate room, there is research finding that parents who share the room with their infants sleep more poorly than parents who have their infant in a crib in a separate room. The parents' mental health and sleep quality needs to be considered as well in making these important decisions. Sleep deprivation, depression, and reduced marital satisfaction can all have a serious negative impact on the baby. The risk of SIDS may be outweighed by these other risks.

The authors state: "There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%," It is not clear whether this statistic refers to room-sharing vs. separate room/crib, but I did not find sound evidence that having infants sleep in the same room with parents on a different surface is less risky than having infants sleep in a separate room in a crib. Here are a few problems I found with the studies cited in support of this statement:

I am skeptical about the logical and empirical support for recommending room-sharing over having the infant sleep in a separate room for the first year of life, and I am very concerned that this recommendation will result in undue stress and other negative consequences for parents who are reluctant to share their room with their infant.

First, even if there was clear support for sharing a room vs having the infant sleep in a crib in a separate room, there is research finding that parents who share the room with their infants sleep more poorly than parents who have their infant in a crib in a separate room. The parents' mental health and sleep quality needs to be considered as well in making these important decisions. Sleep deprivation, depression, and reduced marital satisfaction can all have a serious negative impact on the baby. The risk of SIDS may be outweighed by these other risks.

The authors state: "There is evidence that sleeping in the parents’ room but on a separate surface decreases the risk of SIDS by as much as 50%," It is not clear whether this statistic refers to room-sharing vs. separate room/crib, but I did not find sound evidence that having infants sleep in the same room with parents on a different surface is less risky than having infants sleep in a separate room in a crib. Here are a few problems I found with the studies cited in support of this statement:

1) Some studies are old and predate the recommendation to have infants sleep supine. In at least one study (Scragg et al., 1996) infants may have been at a greater risk in a separate room because they may have been sleeping prone.

2) 'Separate room' in many of these studies doesn't mean sleeping in a crib alone with no soft bedding/blankets. In Blair et al., 1999, a 'solitary sleeper' is an infant who "usually slept in room separate from parents either alone or with other siblings." In Carpenter et al., 2004, “being last left in another room” was associated with greater risk than sleeping with parent but not in the same bed. ‘Another room’ could mean in their own room in a crib alone, or it could mean something else. Thus we don't know that that the reduced risk is purely do to having parents close by to monitor the infant versus some other uncontrolled factors.

3) In many of the studies, some confounding variables are controlled, but not all the relevant variables (e.g., maternal smoking postpartum, alcohol use, bedding/blanket use). Given the strength of the recommendation I’d want to see that all confounds are simultaneously controlled.

At least one study reported that sleeping in a separate room vs shared room was not associated with a higher risk of SIDS in non-smokers.

Also, what supports the recommendation of room sharing for a year vs. six months? I didn't see any research support for this.

This report has a combined section on room-sharing and bed-sharing (recommendation #4). As such it is difficult to discern the SUID-reducing effectiveness of a separate bed vs. a shared room. Does the up to 50% reduction apply to both, or just room-sharing. All else equal, what is the reduction in infant deaths between a child sleeping in their own bed in their caregivers' room vs. sleeping in their own bed in their own room?

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